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Goyal K, Yadav T, Garg PK, Khera P, Tiwari S, Rajagopal R. Pediatric Renovascular Hypertension: A Pediatric Interventional Radiologist's Perspective. Indian J Radiol Imaging 2023; 33:508-513. [PMID: 37811187 PMCID: PMC10556328 DOI: 10.1055/s-0043-1772496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
Renovascular hypertension (RVH) contributes close to one-fourth of the secondary etiologies of hypertension in children and a delay in diagnosis can result in adverse clinical outcomes. RVH in children is clinically silent with elevations in blood pressure measurements sometimes as its sole manifestation. Only a high index of suspicion by the clinician can prompt its detection. Despite the availability of other imaging modalities like ultrasound, computed tomography, and magnetic resonance imaging, digital subtraction angiography is still considered the gold standard to make a diagnosis of RVH. Angioplasty is considered the treatment of choice in appropriately selected patients. In this article, we shall focus on the various imaging findings, and management of RVH in children, which requires a multidisciplinary approach with a special focus on the role of interventional radiology.
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Affiliation(s)
- Kanav Goyal
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Taruna Yadav
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pawan Kumar Garg
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pushpinder Khera
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Sarbesh Tiwari
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Rengarajan Rajagopal
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Abstract
Renovascular hypertension (RVH) is a secondary form of high blood pressure resulting from impaired blood flow to the kidneys with subsequent activation of the renin-angiotensin-aldosterone system. Often, this occurs due to abnormally small, narrowed, or blocked blood vessels supplying one or both kidneys (ie: renal artery occlusive disease) and is correctable. Juxtaglomerular cells release renin in response to decreased pressure, which in turn catalyzes the cleavage of circulating angiotensinogen synthesized by the liver to the decapeptide angiotensin I. Angiotensin-converting enzyme then cleaves angiotensin I to form the octapeptide angiotensin II, a potent vasopressor and the primary effector of renin-induced hypertension. The effects of angiotensin II are mediated by signaling downstream of its receptors. Angiotensin receptor type 1 is a G-protein-coupled receptor that activates vasoconstrictor and mitogenic signaling pathways resulting in peripheral arteriolar vasoconstriction and increased renal tubular reabsorption of sodium and water which promotes intravascular volume expansion. Angiotensin II stimulates the adrenal cortical release of aldosterone, which promotes renal tubular sodium reabsorption, resulting in volume expansion. Angiotensin II acts on glial cells and regions of the brain responsible for blood pressure regulation increasing renal sympathetic activation. Angiotensin II simulates the release of vasopressin from the pituitary which stimulates thirst and water reabsorption from the kidney to expand the intravascular volume and cause peripheral vasoconstriction (increased sympathetic tone). All of these mechanisms coalesce to increase arterial pressure by way of arteriolar constriction, enhanced cardiac output, and the retention of sodium and water.
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Affiliation(s)
- Jessie Dalman
- University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, USA
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Percutaneous cutting balloon angioplasty for the treatment of renovascular hypertension in children and adolescents. J Hypertens 2022; 40:1902-1908. [PMID: 35983863 DOI: 10.1097/hjh.0000000000003162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Percutaneous transluminal renal angioplasty (PTRA), the recommended treatment in children with renovascular hypertension (RVH), often has unsatisfactory outcomes. Cutting balloons may improve the results of angioplasty in different vascular beds with complex and resistant lesions. We retrospectively analysed the effects of percutaneous cutting balloon angioplasty (PCBA) on blood pressure, cardiac mass and renal artery acceleration time in children/adolescents referred to our centre for RVH. PATIENTS AND METHODS Thirteen patients (aged 9-19 years) with renal artery stenosis (RAS) and severe hypertension were identified. RASs were focal fibromuscular (FMD) or FMD-like dysplasia (in six cases bilateral, in five associated with mid aortic syndrome). Ten patients had uncontrolled hypertension, in nine cases associated with left ventricular hypertrophy (LVH). Acceleration time was abnormal in all stenotic arteries. Eighteen PCBA were performed, in three arteries associated with stent implantation. RESULTS PCBA was technically successful in all individuals without major complications. In one patient, an intra-stent restenosis occurred, successfully redilated with conventional angioplasty without recurrence at 4 years distance. One year after PCBA, mean SBP and DBPs were markedly reduced from 146 ± 25 to 121 ± 10 mmHg and from 87 ± 11 to 65 ± 12 mmHg, respectively (P < 0.001 for both). At that time, hypertension was cured in seven children and controlled in five individuals. This favourable outcome was confirmed with ambulatory blood pressure measurement in four patients. At the latest follow-up, left ventricular mass and acceleration time were normal in all patients. CONCLUSION PCBA proved to be a well tolerated and effective procedure that can be considered as an alternative to PTRA to treat hypertensive children/adolescents with recurrent or resistant RAS.
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Stanley JC. Renal Artery Occlusive Disease, Renin-Angiotensin-Aldosterone, Inflammation and Refractory Arterial Hypertension, A Half-Century’s Perspective. J Vasc Surg 2022; 76:46-52. [DOI: 10.1016/j.jvs.2022.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 02/19/2022] [Indexed: 10/18/2022]
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Renovascular hypertension in pediatric patients: update on diagnosis and management. Pediatr Nephrol 2021; 36:3853-3868. [PMID: 33851262 DOI: 10.1007/s00467-021-05063-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/11/2021] [Accepted: 03/19/2021] [Indexed: 01/03/2023]
Abstract
Renovascular hypertension (RVH) is defined as an elevated blood pressure caused by kidney hypoperfusion, generally as a result of anatomic stenosis of the renal artery with consequent activation of the Renin Angiotensin-Aldosterone System. The main causes include genetic and inflammatory disorders, extrinsic compression, and idiopathic alterations. RVH is often asymptomatic and should be suspected in any child with refractory hypertension, especially if other suggestive findings are present, including those with severe hypertension, abdominal bruit, and abrupt fall of glomerular filtration rate after administration of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers. There is a consensus that digital subtraction angiography is the gold standard method for the diagnosis of RVH. Nevertheless, the role of non-invasive imaging studies such as Doppler ultrasound, magnetic resonance angiography, or computed tomographic angiography remains controversial, especially due to limited pediatric evidence. The therapeutic approach should be individualized, and management options include non-surgical pharmacological therapy and revascularization with percutaneous transluminal renal angioplasty (PTRA) or surgery. The prognosis is related to the procedure performed, and PTRA has a higher restenosis rate compared to surgery, although a decreased risk of complications. This review summarizes the causes, physiopathology, diagnosis, treatment, and prognosis of RVH in pediatric patients. Further studies are required to define the best approach for RVH in children.
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Sivasubramanian R, Meyers KE. Hypertension in Children and Adolescents with Turner Syndrome (TS), Neurofibromatosis 1 (NF1), and Williams Syndrome (WS). Curr Hypertens Rep 2021; 23:18. [PMID: 33779870 DOI: 10.1007/s11906-021-01136-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2021] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW Turner syndrome (TS), neurofibromatosis type 1(NF1), and William Syndrome (WS) are 3 genetic conditions that are all associated with a substantial increase in risk of hypertension. In this review, we focus on factors leading to hypertension and on clinical manifestations and management of hypertension in children and adolescents with these genetic conditions RECENT FINDINGS: In most instances, hypertension is secondary. There is a high prevalence of masked hypertension in TS; however, the extent to which control of the BP helps reduce the risk of aortic dissection/aneurysm in TS is not yet fully elucidated. Vasculopathies are the least emphasized but most important manifestation of NF1. Of note, routine screening for pheochromocytoma in NFI is not recommended as it is not cost-effective. Cardiovascular complications are the major cause of death in patients with WBS. ABPM identifies patients without overt aortic or renovascular narrowing. Antihypertensive agents such as ARBs that have direct vascular wall effects and agents that inhibit oxidative stress (minoxidil) should be considered, even in those who do not exhibit overt hypertension. Elevated blood pressure in children and adolescence manifests early with end-organ changes and when left untreated, increases risk for premature onset of cardiovascular disease. Vigilant monitoring of the blood pressure is recommended. Accurate early diagnosis and management of hypertension will delay or prevent target organ damage and ensure a healthier transition to adulthood among children afflicted with these conditions.
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Affiliation(s)
- Ramya Sivasubramanian
- Division of Pediatric Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia, 9th Floor Beurger Building, 3405 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Kevin E Meyers
- Division of Pediatric Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, 9th Floor Beurger Building, 3405 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
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Orman G, Masand PM, Kukreja KU, Acosta AA, Guillerman RP, Jadhav SP. Diagnostic sensitivity and specificity of CT angiography for renal artery stenosis in children. Pediatr Radiol 2021; 51:419-426. [PMID: 33151345 DOI: 10.1007/s00247-020-04852-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 08/14/2020] [Accepted: 09/10/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Children with suspected renal artery stenosis (RAS) are screened with renal Doppler ultrasonography or computed tomography (CT) angiography/magnetic resonance (MR) angiography depending on institutional preference. CT angiography produces images with superior resolution, allowing higher quality multiplanar two-dimensional reformats and three-dimensional reconstructions. However, there is a paucity of data in the literature regarding the utility and diagnostic performance of renal CT angiography in pediatric RAS. OBJECTIVE The objective of this study is to retrospectively review our experience with renal CT angiography in the diagnosis of pediatric RAS relative to digital subtraction angiography (DSA) as the reference standard. MATERIALS AND METHODS All patients 0-18 years of age who underwent CT angiography for evaluation of RAS as a cause of hypertension between January 2012 and May 2019 were identified for the study. A total of 131 patients were identified, 23 of whom had DSA correlation. RESULTS Twenty-three patients (17 boys, 6 girls) with a mean age of 6 years 3 months (range: 3 months to 14 years 7 months) were included in this study. Of the 59 renal arteries studied by DSA, 22 were abnormal on CT angiography and 20 were abnormal on DSA. Of the 59 renal arteries, CT angiography was true positive in 18 and true negative in 35. The sensitivity and specificity of CT angiography for RAS diagnosis were 90.0% and 89.7%, respectively. CT angiography identified all cases of main RAS. CONCLUSION Renal CT angiography has a high sensitivity and specificity for pediatric RAS diagnosis in patients referred for DSA.
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Affiliation(s)
- Gunes Orman
- Edward B. Singleton Department of Radiology, Texas Children's Hospital, 6701 Fannin Street, Suite 470, Houston, TX, 77030, USA.
| | - Prakash M Masand
- Edward B. Singleton Department of Radiology, Texas Children's Hospital, 6701 Fannin Street, Suite 470, Houston, TX, 77030, USA
| | - Kamlesh U Kukreja
- Edward B. Singleton Department of Radiology, Texas Children's Hospital, 6701 Fannin Street, Suite 470, Houston, TX, 77030, USA
| | - Alisa A Acosta
- Renal Section, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - R Paul Guillerman
- Edward B. Singleton Department of Radiology, Texas Children's Hospital, 6701 Fannin Street, Suite 470, Houston, TX, 77030, USA
| | - Siddharth P Jadhav
- Edward B. Singleton Department of Radiology, Texas Children's Hospital, 6701 Fannin Street, Suite 470, Houston, TX, 77030, USA
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Abstract
Paediatric hypertension, defined as systolic blood pressure > 95th percentile for age, sex and height is often incidentally diagnosed. Renovascular hypertension (RVH) is responsible for 5-25% of hypertension in children. Renal artery stenosis and middle aortic syndrome can both can be associated with various conditions such as fibromuscular dysplasia, Williams syndrome & Neurofibromatosis type 1. This paper discusses the approaches to diagnosis and interventional management and outcomes of renovascular hypertension in children. Angiography is considered the gold standard in establishing the diagnosis of renovascular disease in children. Angioplasty is beneficial in the majority of patients and generally repeated angioplasty is considered more appropriate than stenting. Surgical options should first be considered before placing a stent unless there is an emergent requirement. Given the established safety and success of endovascular intervention, at most institutions it remains the preferred treatment option.
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Affiliation(s)
- Premal Amrishkumar Patel
- Interventional Radiology, Radiology Department, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK.
| | - Anne Marie Cahill
- Interventional Radiology, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Coleman DM, Eliason JL, Beaulieu R, Jackson T, Karmakar M, Kershaw DB, Modi ZJ, Ganesh SK, Khaja MS, Williams D, Stanley JC. Surgical management of pediatric renin-mediated hypertension secondary to renal artery occlusive disease and abdominal aortic coarctation. J Vasc Surg 2020; 72:2035-2046.e1. [PMID: 32276020 DOI: 10.1016/j.jvs.2020.02.045] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 02/15/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Renovascular hypertension (RVH) associated with renal artery and abdominal aortic narrowings is the third most common cause of pediatric hypertension. Untreated children may experience major cardiopulmonary complications, stroke, renal failure, and death. The impetus of this study was to describe the increasingly complex surgical practice for such patients with an emphasis on anatomic phenotype and contemporary outcomes after surgical management as a means of identifying those factors responsible for persistent or recurrent hypertension necessitating reoperation. METHODS A retrospective analysis was performed of consecutive pediatric patients with RVH undergoing open surgical procedures at the University of Michigan from 1991 to 2017. Anatomic phenotype and patient risk factors were analyzed to predict outcomes of blood pressure control and the need for secondary operations using ordered and binomial logistic multinomial regression models, respectively. RESULTS There were 169 children (76 girls, 93 boys) who underwent primary index operations at a median age of 8.3 years; 31 children (18%) had neurofibromatosis type 1, 76 (45%) had abdominal aortic coarctations, and 28 (17%) had a single functioning kidney. Before treatment at the University of Michigan, 51 children experienced failed previous open operations (15) or endovascular interventions (36) for RVH at other institutions. Primary surgical interventions (342) included main renal artery (136) and segmental renal artery (10) aortic reimplantation, renal artery bypass (55), segmental renal artery embolization (10), renal artery patch angioplasty (8), resection with reanastomosis (4), and partial or total nephrectomy (25). Non-renal artery procedures included patch aortoplasty (32), aortoaortic bypass (32), and splanchnic arterial revascularization (30). Nine patients required reoperation in the early postoperative period. During a mean follow-up of 49 months, secondary interventions were required in 35 children (21%), including both open surgical (37) and endovascular (14) interventions. Remedial intervention to preserve primary renal artery patency or a nephrectomy if such was impossible was required in 22 children (13%). The remaining secondary procedures were performed to treat previously untreated disease that became clinically evident during follow-up. Age at operation and abdominal aortic coarctation were independent predictors for reoperation. The overall experience revealed hypertension to be cured in 74 children (44%), improved in 78 (46%), and unchanged in 17 (10%). Children undergoing remedial operations were less likely (33%) to be cured of hypertension. There was no perioperative death or renal insufficiency requiring dialysis after either primary or secondary interventions. CONCLUSIONS Contemporary surgical treatment of pediatric RVH provides a sustainable overall benefit to 90% of children. Interventions in the very young (<3 years) and concurrent abdominal aortic coarctation increase the likelihood of reoperation. Patients undergoing remedial surgery after earlier operative failures are less likely to be cured of hypertension. Judicious postoperative surveillance is imperative in children surgically treated for RVH.
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Affiliation(s)
- Dawn M Coleman
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.
| | - Jonathan L Eliason
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Robert Beaulieu
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Tatum Jackson
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Monita Karmakar
- Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - David B Kershaw
- Division of Pediatric Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, Mich
| | - Zubin J Modi
- Division of Pediatric Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, Mich; Susan B. Meister Child Evaluation and Research Center, University of Michigan, Ann Arbor, Mich
| | - Santhi K Ganesh
- Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor, Mich; Department of Human Genetics, University of Michigan, Ann Arbor, Mich
| | - Minhaj S Khaja
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan, Ann Arbor, Mich
| | - David Williams
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan, Ann Arbor, Mich
| | - James C Stanley
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
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Villegas L, Cahill AM, Meyers K. Pediatric Renovascular Hypertension: Manifestations and Management. Indian Pediatr 2020. [DOI: 10.1007/s13312-020-1820-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Okumura K, Vidi S, Desai DM. Renal auto transplantation for renovascular hypertension associated with bifurcated renal artery stenosis in a pediatric patient. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2019. [DOI: 10.1016/j.epsc.2018.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Louis R, Levy-Erez D, Cahill AM, Meyers KE. Imaging studies in pediatric fibromuscular dysplasia (FMD): a single-center experience. Pediatr Nephrol 2018; 33:1593-1599. [PMID: 29869115 PMCID: PMC6082421 DOI: 10.1007/s00467-018-3983-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Fibromuscular dysplasia (FMD) is a non-inflammatory vascular disease that in children unlike in adults shows no sex predilection. FMD is often underdiagnosed, and its pathophysiology is unclear. Delayed diagnosis may lead to refractory hypertension and decreases the chance of successful treatment. Doppler ultrasound (US), magnetic resonance angiography (MRA), computed tomography angiography (CTA), and catheter-based angiography (angiography) are currently used to help make a clinicoradiological diagnosis of FMD. The main aim of the study was to compare the efficacy of imaging modalities which can allow for earlier and improved detection. Furthermore, an anatomical mapping of the location of lesions can help determine the best treatment modalities. METHODS All patients with non-syndromic non-inflammatory renovascular hypertension were recruited from the Nephrology Department at the Children's Hospital of Philadelphia (CHOP) and enrolled in the U.S. FMD Registry maintained at the University of Michigan. Clinical presentation and imaging findings on US, CT, and MRI of children diagnosed with FMD were evaluated. RESULTS Mean age at diagnosis was 7 ± 4.9 years (4 months-17 years). Family history of hypertension (HTN) (52%), FMD (8.7%), Caucasian (60%), headache (48%), and HTN (80%) were the most prevalent symptom and sign at presentation. Bruits were 100% specific for renal artery stenosis (RAS) diagnosis but were heard in the minority of patients (3 patients, 12%). FMD was mainly unifocal within a single site (68%) or multiple sites (28%) and involved the main or first order renal branch in about 68% of children. Isolated distal lesions beyond the second order branches were found in about 25% of children. US imaging was significantly less sensitive than angiography (28%, p = 0.003). MRA had a better sensitivity (62.5%, p = 0.3) than US. Overall, CTA had the best sensitivity (84.2%, p = 0.4) compared to angiography; however, only angiography showed distal vessel disease. CONCLUSIONS Limitations of the study include the sample size and biases-only patients diagnosed with FMD were included in this study and most patients were referred to a pediatric nephrologist for unexplained hypertension. Angiography should be performed as part of the initial work-up of any child suspected of having renovascular FMD, regardless of the findings seen on US, MRA, or CTA.
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Affiliation(s)
- Robert Louis
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- University of Pennsylvania, Philadelphia, PA, USA
| | - Daniella Levy-Erez
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- University of Pennsylvania, Philadelphia, PA, USA.
| | - Anne Marie Cahill
- University of Pennsylvania, Philadelphia, PA, USA
- Interventional Radiology, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kevin E Meyers
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- University of Pennsylvania, Philadelphia, PA, USA
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Lobeck IN, Alhajjat AM, Dupree P, Racadio JM, Mitsnefes MM, Karns R, Tiao GM, Nathan JD. The management of pediatric renovascular hypertension: a single center experience and review of the literature. J Pediatr Surg 2018; 53:1825-1831. [PMID: 29397961 DOI: 10.1016/j.jpedsurg.2017.12.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 11/06/2017] [Accepted: 12/10/2017] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Renal artery occlusive disease is poorly characterized in children; treatments include medications, endovascular techniques, and surgery. We aimed to describe the course of renovascular hypertension (RVH), its treatments and outcomes. METHODS We performed literature review and retrospective review (1993-2014) of children with renovascular hypertension at our institution. Response to treatment was defined by National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents at most-recent follow-up. RESULTS We identified 39 patients with RVH. 54% (n=21) were male, with mean age of 6.93 ± 5.27 years. Most underwent endovascular treatment (n=17), with medication alone (n=12) and surgery (n=10) less commonly utilized. Endovascular treatment resulted in 18% cure, 65% improvement and 18% failure; surgery resulted in 30% cure, 50% improvement and 20% failure. Medication alone resulted in 0% cure, 75% improvement and 25% failure. 24% with endovascular treatment required secondary endovascular intervention; 18% required secondary surgery. 20% of patients who underwent initial surgery required reoperation for re-stenosis. Mean follow-up was 52.2 ± 58.4 months. CONCLUSIONS RVH treatment in children includes medications, surgical or endovascular approaches, with all resulting in combined 79% improvement in or cure rates. A multidisciplinary approach and individualized patient management are critical to optimize outcomes. TYPE OF STUDY Retrospective comparative study LEVEL OF EVIDENCE: Level III.
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Affiliation(s)
- Inna N Lobeck
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Amir M Alhajjat
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Phylicia Dupree
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - John M Racadio
- Department of Radiology and Medical Imaging, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mark M Mitsnefes
- Division of Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Rebekah Karns
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Greg M Tiao
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jaimie D Nathan
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
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Pio L, Avanzini S, Mattioli G, Martucciello G, Sementa AR, Conte M, Gigliotti A, Granata C, Leva E, Fagnani AM, Caccioppoli U, Tedesco N, Schleef J, Tirtei E, Siracusa F, D'Angelo P, Lelli Chiesa P, Miglionico L, Noccioli B, Severi E, Carlini C, Vaccarella F, Camoglio F, Cesaro S, Narciso A, Riccipetitoni G, Cecchetto G, Inserra A. Perioperative management of hypertensive neuroblastoma: A study from the Italian Group of Pediatric Surgical Oncologists (GICOP). J Pediatr Surg 2017; 52:1633-1636. [PMID: 28711167 DOI: 10.1016/j.jpedsurg.2017.06.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 06/13/2017] [Accepted: 06/29/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND Hypertension (HT) is rarely reported in patients affected by Neuroblastoma (NB), and management guidelines are lacking. Clinical features and perioperative medical treatment in such patients were reviewed to 1) ascertain whether a shared treatment strategy exists among centers and 2) if possible, propose some recommendations for the perioperative management of HT in NB patients. METHODS A retrospective multicenter survey was conducted on patients affected by NB who presented HT symptoms. RESULTS From 2006 to 2014, 1126 children were registered in the Italian Registry of Neuroblastoma (RINB). Of these, 21 with HT (1.8%) were included in our analysis. Pre- and intraoperative HT management was somewhat dissimilar among the participating centers, apart from a certain consistency in the intraoperative use of the alpha-1 blocker urapidil. Six of the 21 patients (28%) needed persistent antihypertensive treatment at a median follow-up of 36months (range 4-96months) despite tumor removal. Involvement of the renal pedicle was the only risk factor constantly associated to HT persistency following surgery. A correlation between the presence of HT and the secretion of specific catecholamines and/or compression of the renal vascular pedicle could not be demonstrated. CONCLUSION Based on this retrospective review of NB patients with HT, no definite therapeutic protocol can be recommended owing to heterogeneity of adopted treatments in different centers. A proposal of perioperative HT management in NB patients is however presented. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Luca Pio
- Pediatric Surgery Unit, Istituto Giannina Gaslini, Genova; DINOGMI, Università Degli Studi di Genova.
| | | | - Girolamo Mattioli
- Pediatric Surgery Unit, Istituto Giannina Gaslini, Genova; DINOGMI, Università Degli Studi di Genova
| | - Giuseppe Martucciello
- Pediatric Surgery Unit, Istituto Giannina Gaslini, Genova; DINOGMI, Università Degli Studi di Genova
| | | | | | - Annarita Gigliotti
- Epidemiology Biostatistics and Committees Unit, Istituto Giannina Gaslini, Genova
| | | | - Ernesto Leva
- Pediatric Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano
| | - Anna Maria Fagnani
- Pediatric Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano
| | | | - Nino Tedesco
- Surgical Oncology Unit, A.O.R.N. Santobono Pausilipon, Napoli
| | - Jurgen Schleef
- Pediatric Surgery Unit, Ospedale Infantile Regina Margherita, Torino
| | - Elisa Tirtei
- Oncology Unit, Ospedale Infantile Regina Margherita, Torino
| | | | - Paolo D'Angelo
- Oncology Unit, A.R.N.A.S. Civico, Di Cristina and Benfratelli Hospital, Palermo
| | | | - Lucia Miglionico
- Oncology Unit, Casa Sollievo della Sofferenza, San Giovanni Rotondo
| | - Bruno Noccioli
- Pediatric Surgery Unit, Ospedale Pediatrico Meyer, Firenze
| | - Elisa Severi
- Pediatric Surgery Unit, Ospedale Pediatrico Meyer, Firenze
| | - Claudio Carlini
- Pediatric Surgery Unit, ASN SS: Antonio e Biagio e Cesare Arrigo, Alessandria
| | | | - Francesco Camoglio
- Pediatric Surgery Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Verona
| | - Simone Cesaro
- Oncology Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Verona
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15
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Yoo R, Alomari AI, Shaikh R, Davis SL, Ferguson MA, Vakili K, Kim HB, Chaudry G. Catheter-Directed Thrombolysis in a Child with Bilateral Renal Artery Graft Thrombosis. J Vasc Interv Radiol 2017; 28:1184-1188. [DOI: 10.1016/j.jvir.2016.04.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 04/17/2016] [Accepted: 04/18/2016] [Indexed: 11/26/2022] Open
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16
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Thorsteinsdottir H, Dorenberg E, Line PD, Bjerre A. [Renovascular disease in children - a rare diagnosis with few symptoms]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2017; 137:279-282. [PMID: 28225234 DOI: 10.4045/tidsskr.16.0156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND To estimate the prevalence, symptoms, causes and treatment of renovascular disease in children, and also to assess the degree of secondary organ damage to the heart, kidneys and eyes (end organ damage).MATERIAL AND METHOD Retrospective review of data for all children (0 - 16 years) who were examined for resistant hypertension in the period 1998 - 2013 at Oslo University Hospital Rikshospitalet.RESULTS A total of 21 children/adolescents (median age 8.5 years, 11 girls) were assessed and treated for resistant hypertension in the study period. Altogether had 38 % no symptoms at the time of diagnosis and 19 % had classical symptoms of hypertension. Fifteen patients received invasive treatment in the form of percutaneous transluminal renal angioplasty (PTRA) (n = 5), nephrectomy (n = 6), coiling (n = 1), autotransplantation (n = 1) or a combination of these (n = 2). Blood pressure improved following treatment in 10 of 14 patients for whom outcomes were recorded in the medical records. End organ damage to the heart and retina was observed in 60 % and 50 % of patients, respectively.INTERPRETATION Children with severely elevated blood pressure as a result of renovascular disease often have unspecific or no symptoms. Blood pressure improved following invasive treatment in 10 of 14 children and few complications were recorded. Invasive treatment may be considered in children and adolescents when standard treatment for hypertension is insufficient.
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Affiliation(s)
| | | | - Pål-Dag Line
- Avdeling for transplantasjonsmedisin og Institutt for klinisk medisin Universitetet i Oslo
| | - Anna Bjerre
- Barne- og ungdomsklinikken Oslo universitetssykehus
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17
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Remedial operations for failed endovascular therapy of 32 renal artery stenoses in 24 children. Pediatr Nephrol 2016; 31:809-17. [PMID: 26628283 DOI: 10.1007/s00467-015-3275-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 11/09/2015] [Accepted: 11/10/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Percutaneous transluminal angioplasty (PTA) for the treatment of pediatric renovascular hypertension (RVH) in contemporary practice is accompanied with ill-defined complications. This study examines the mode of pediatric renal PTA failures and the results of their surgical management. METHODS Twenty-four children underwent remedial operations at the University of Michigan from 1996 to 2014 for failures of renal PTA. Their clinical courses were retrospectively reviewed and results analyzed. RESULTS Renal PTA of 32 arteries, including 13 with stenting, was performed for severe RVH in 12 boys and 12 girls, having a mean age of 9.3 years. Developmental ostial stenoses affected 22 children. PTA failures included: 27 restenoses and five thromboses. Remedial operations included: 13 renal artery-aortic reimplantations, one segmental renal artery-main renal artery reimplantation, ten aortorenal bypasses, one arterioplasty, one iliorenal bypass, and six nephrectomies for unreconstructable arteries; the latter all in children younger than 10 years. Follow-up averaged 2.1 years. Postoperatively, hypertension was cured, improved, or unchanged in 25, 54, and 21 %, respectively. There was no perioperative renal failure or mortality. CONCLUSIONS Renal PTA for the treatment of pediatric RVH due to ostial disease may be complicated by failures requiring complex remedial operations or nephrectomy, the latter usually affecting younger children.
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18
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Green R, Gu X, Kline-Rogers E, Froehlich J, Mace P, Gray B, Katzen B, Olin J, Gornik HL, Cahill AM, Meyers KE. Differences between the pediatric and adult presentation of fibromuscular dysplasia: results from the US Registry. Pediatr Nephrol 2016; 31:641-50. [PMID: 26525198 DOI: 10.1007/s00467-015-3234-z] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 09/22/2015] [Accepted: 09/23/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Fibromuscular dysplasia (FMD) is a non-inflammatory arteriopathy that causes significant morbidity in children. METHODS The clinical features, presenting symptoms, and vascular beds involved are reviewed in the first 33 patients aged <18 years who are enrolled in the United States Registry for FMD from five registry sites and compared with 999 adult patients from 12 registry sites. RESULTS Mean age at diagnosis was 8.4 ± 4.8 years (16 days to 17 years). Compared with adults, pediatric FMD occurs in more males (42.4 vs 6 %, p < 0.001). Children with FMD have a stronger previous history of hypertension (93.9 vs 69.9 %, p = 0.002). Hypertension (100 %), headache (55 %), and abdominal bruits (10.7 %) were the most common presenting signs and symptoms. FMD affects renal vasculature in almost all children (97 vs 69.7 %, p = 0.003). The extra-cranial carotid vessels are less commonly involved in children (23.1 vs 73.3 %, p < 0.001). The mesenteric arteries (38.9 vs 16.2 %, p = 0.02) and aorta (26.3 vs 2.4 %, p < 0.001) are more commonly involved in children. CONCLUSIONS In the United States Registry for FMD, pediatric FMD affects children from infancy throughout childhood. All children presented with hypertension and many presented with headache and abdominal bruits. In children, FMD most commonly affects the renal vasculature, but also frequently involves the mesenteric arteries and abdominal aorta; the carotid vessels are less frequently involved.
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Affiliation(s)
- Rebecca Green
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,The Children's Hospital of Philadelphia, Philadelphia, PA, USA. .,Division of General Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania, 9NW63, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104-4399, USA.
| | - Xiaokui Gu
- University of Michigan, Ann Arbor, MI, USA
| | | | | | - Pamela Mace
- Fibromuscular Dysplasia Society of America, Rocky River, OH, USA
| | - Bruce Gray
- Greenville Health System, Greenville, SC, USA
| | - Barry Katzen
- Miami Baptist Cardiac/Vascular Institute, Miami, FL, USA
| | - Jeffrey Olin
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Ann Marie Cahill
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kevin E Meyers
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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19
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Jerónimo M, Dionísio T, Gomes C, Neves JF. Renovascular hypertension: a case with atypical neurological signs. BMJ Case Rep 2015; 2015:bcr-2014-208336. [PMID: 26351310 DOI: 10.1136/bcr-2014-208336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Secondary hypertension is the most frequent form of hypertension in children. Renovascular disease accounts for 5-10% of all childhood hypertension and should be suspected in the presence of severe hypertension found difficult to manage with medical therapy. Uncontrolled hypertension can lead to severe target organ damage. We describe the case of a 13-month-old baby boy with failure to thrive, recent muscular weakness of the lower extremities and irritability. Hypertension was detected and he was admitted to the paediatric intensive care unit with a refractory hypertensive emergency, despite multiple antihypertensive therapies. Bilateral renal artery stenosis was diagnosed through renal angiography and balloon dilation was performed, leading to lower blood pressure. He is currently withdrawing from antihypertensive medication, and slowly gaining weight and recovering from target organ damage. However, weakness of the lower extremities persists and he has been diagnosed with a neurogenic bladder.
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Affiliation(s)
| | - Teresa Dionísio
- Pediatric Intensive Care Unit, Hospital Pediátrico de Coimbra, Coimbra, Portugal
| | - Clara Gomes
- Department of Paediatric Nephrology, Hospital Pediátrico de Coimbra, Coimbra, Portugal
| | - José Farela Neves
- Pediatric Intensive Care Unit, Hospital Pediátrico de Coimbra, Coimbra, Portugal
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